Leeds City Schools

Leeds City Schools

LEEDS CITY SCHOOLS

EXTENDED DAY PROGRAM

2015-2016 APPLICATION

SITE DIRECTORS: LYN HOPKINS, MARGARET HUGHES, MERRY TICE

(205) 910-4427

DISTRICT DIRECTOR: BURKE WREN

(205) 699-5437 EXT. 8

LEEDS CITY SCHOOLS

2015-16 EXTENDED DAY PROGRAM

It is the policy of the Leeds City Schools Board of Education not to discriminate on the basis of sex, color, disability, religion, creed, national origin, race, or age, in its educational programs, activities, or employment policies as required by federal regulations.

REGISTRATION APPLICATION

By completing this packet, you are registering your child to attend Leeds City Schools 2015­2016 Extended Day Care.

HOURS OF OPERATION

Before School Care- Monday through Friday from 6:30 a.m. to 7:30 a.m.

After School Care- Monday through Friday from 3:10 p. m. through 6:00 p.m.

A fee of $1 per minute late will be charged for any child/children not picked up on time. We offer after school care for students who are in the preschool program at Leeds Elementary School which begins at preschool dismissal each day to those who wish to sign up.

Child's Name ______

Last First Nickname

Date of Birth ______Age______Teacher______Grade Level 2015-2016______

Street Address______City______State____Zip-code______

Mother’s Name______Home/Cell Phone______Work Phone______

Email Address______

Father’s Name______Home/Cell Phone______Work Phone______

Email Address______

Person(s) having custody of this child: ______

Is this child currently receiving special education services? Yes__ No__ If yes, does the child require any special accommodations? This must be supported and documented in the IEP. Please explain:

______

PICK UP: Persons with permission to pick up child other than parents:

1. ______Relationship ______Phone ______

2. ______Relationship ______Phone ______

3. ______Relationship ______Phone ______

4. ______Relationship ______Phone ______

IN CASE OF EMERGENCY, CONTACT:

1. ______Relationship ______Phone ______

2. ______Relationship ______Phone ______

3. ______Relationship ______Phone ______

4. ______Relationship ______Phone ______

MEDICAL INFORMATION: (allergies, nosebleeds, insect bites, etc.) YES ___NO ___

Ifyes, please explain issues. (Extended Care staff are not allowed to administer medications).

______

Physician's Name ______Phone ______

If your child is contagious with anything, he/she will need to be non­contagious before returning to after school care. In other words, the child must be fever-free for one full day without medication. In case ofthe flu or similar illness, you must have a physician’s note releasing the child from his/her care.

In case of emergency, the Leeds City Schools staff has my permission to secure medical

attention for my child.

YES___ NO ___

Signature of Parent or Guardian Date

Is the child covered by health insurance? Yes____ No ____

Insurance Carrier & Contract No. ______

Pleaseprovide a copy of the insurance card(s) front and back.

BEHAVIOR

  • I understand my child must abide by the Leeds City Schools Code of Conduct and will work with the staff to make sure my child follows the rules and works cooperatively with the students and staff.
  • No corporal punishment shall be administered. When a child exhibits disruptive behavior, such as, but not limited to: fighting, abusive language, disrespect or disobedience, it will be noted in the Discipline Log. Parents will be notified. Infractions may result in immediate dismissal.
  • An accumulation of three (3) infractions recorded in the Discipline Log may result in a three (3) day suspension or dismissal.
  • Ifat any time a child's behavior endangers the safety of himself/herself or others, the child may be dismissed from the program immediately.
  • Discipline problems will be noted in the Discipline Log. This information will be available to parents upon request. The discipline will be similar to Leeds City Schools Code of Conduct as applies to Class I infractions resulting in time-outs and other minor consequences and Class II infractions resulting in suspensions or dismissal.
  • I understand my child can be released from this program for unacceptable or inappropriate behavior. If it is summer care, the child may be removed from field trips and other activities at the discretion of the site directors.

I have read the above statements carefully. My child and I agree to abide by them.

Parent's/Guardian's Signature: ______Date ______

MEDIA RELEASE

Leeds City Schools communicates information including, but not limited to, photographs and interviews about our program and activities on our website and with the media. I give permission and understand that photographs and interviews will be of my child and published in newsletters, on the school system website, local and state newspapers, and other media publications without further permission. This permission and release shall be effective for the current school year.

Parent's/Guardian's Signature:______Date ______

AGREEMENT TO PAY FEES

  • I understand and agree to pay the registration and weekly fees for my child to attend the Leeds City Schools Extended Day Care.
  • I understand the registration fee is $35 and non-refundable and is due with the completed enrollment packet and first weeks fee.
  • I understand I am expected to pay the total weekly fee each Friday for the upcoming week.
  • I understand payment for the full week is due each week whether my child attends each day or is absent.
  • I understand that all payments must be made in advance and that any unpaid balance carried into the next week will be subject to a $10 late charge. I realize it is my responsibility and obligation to pay for these services promptly and on a regular basis.
  • I understand that ifmy payments become past due, my child will not be able to return to the program until all payments are brought up to date.
  • I understand there is a $1 charge for every minute after the daily hours (6:00 p.m.) that I fail to pick up my child and that this amount is due and payable at the time my child is picked up.
  • I understand that I if have a check not honored by my bank, my check will be turned over to the accounting department which submits to a third party company for collection.
  • I understand that if I stop paying before the end of the program, my child can be denied attendance to Leeds City School Extended Day Program and Summer Care Programs in the future.
  • Ifyou are planning to withdraw your child, please let us know at least one week in advance in writing and all fees must be paid in full.

I have read the above statements and I agree to abide by them.

Parent/Guardian Signature: ______Date ______

INCLEMENT WEATHER PLAN

Leeds Extended Day Care will follow the same procedures for closing that the system follows. Ifby chance, the weather is after the school day, parents will be called ifthe program is closing. We MUST have accurate phone numbers to reach all parents in case of emergency closings. Please let the director(s) know ifyou are better reached by email or some other means in case of emergency weather dismissal.

IT IS IMPERATIVE THAT WE HAVE A WAY TO REACH YOU QUICKLY

Emergency phone number and/or e-mail: ______

Name of emergency contact ______

Forms and Fees should be returned to Leeds Elementary School no later than August 7, 2015 to secure admission to the program prior to the start of school.

If coming to the program later, forms will be accepted by Ms. Hopkins, Ms. Tice or Ms. Hughes.

Weekly Rates:

  • Extended Day(only) $40 per week
  • Extended Day and Morning Care $50 per week
  • Morning Care(only) $10 per week

Ifthere are any problems not resolved with the site directors, please contact

Dr. Burke Wren at 699-5437 ext. 8.

Top View